Abstract
Background
Botulism is a rare potentially fatal and treatable disorder caused by a bacteria-produced toxin that affects the presynaptic synaptic membrane resulting in a characteristic neuromuscular dysfunction. It is caused by either the ingestion of the toxin or the bacteria, inhalation, or wound infection. We present our observations with a descriptive case series of wound botulism secondary to black tar heroin (BTH) injection.
Methods
We report a retrospective single-center case series of 15 consecutive cases of wound botulism presenting to University Medical Center of El Paso. Medical records where reviewed to obtain demographic information, clinical presentation, treatment, and outcome.
Results
We identified fifteen patients with mean age of 47 years: twelve men, and three women. All had administered BTH through skin popping and had abscesses in the administration areas. By history, the most common symptoms were dysphagia (66%), proximal muscle weakness of upper and lower extremity (60%), neck flexor muscle weakness (33%), ophthalmoplegia (53%), bilateral ptosis (46%), dysarthria (53%), double vision (40%), blurred vision (33%), and dry mouth (20%). During the examination, the most common features noted were: proximal muscle weakness of upper and lower extremities (73%), ophthalmoplegia (53%), ptosis (46%). In patients with documented wound botulism, the pupils were reactive in 46%. All patients required mechanical ventilation and were treated with the trivalent antitoxin. Eleven patients (73.3%) were discharged home, two were transferred to a skill nursing facility, and two were transferred to long-term acute care facility.
Conclusion
In our patients, BTH injection, involving the action of injecting under the skin acetylated morphine derivatives (mostly 6-monoacetylmorphine and 3-monoacetylmorphine), was associated with the development of botulism. The availability of BTH at the US–Mexican border is not surprising since it is frequently produced in Latin America. Its association with the development of botulism should be recognized early to allow a prompt diagnosis and treatment with the antitoxin. A clinical feature worth noting is the presence of normal pupillary light reflex in nearly half of patients. Therefore, the presence of a normal pupillary response does not exclude the presence of wound botulism.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Davis LE, King MK. Wound botulism from heroin skin popping. Curr Neurol Neurosci Rep. 2008;8:462–8.
Abavare L, Abavare C. Tupelo. Wound botulism resulting from heroin abuse: can you recognize it? 2011. J Emerg Nurs. 2012;38:301–3.
MacDonald KL, Rutherford GW, Friedman SM, et al. Botulism and botulism like illness in chronic drug users. Ann Intern Med. 1985;102:616–8.
Ciccarone D. Heroin in brown, black and white: structural factors and medical consequences in the US heroin market. Int J Drug Policy. 2009;20:277–82.
Merson MH, Dowell VR. Epidemiologic, clinical and laboratory aspects of wound botulism. N Eng J Med. 1973;289:1105–10.
Shapiro R, Hatheway C, Swerdlow DL. Botulism in the United States: a clinical and epidemiological review. Ann Intern Med. 1998;129(3):221–8.
Hathway CL. Botulism—the present status of disease. In: Montecocco C, editor. Clostridial neurotoxins—current topics in microbiology and immunology, vol. 195. New York: Springer; 1995. p. 55.
Gonzales Y Tucker RD, Frazee B. View from the front lines: an emergency medicine perspective on clostridial infections in injection drug users. Anaerobe. 2014;30:108–15.
Brett MM, Hood J, Brazier JS, Duerden BI, Hahne SJM. Soft tissue infections caused by caused by spore-forming bacteria in injecting drug users in the United Kingdom. Epidemiol Infect. 2005;133:575–82.
Woodruff BA, Giffin PM, McCroskey LM, et al. Clinical and laboratory comparison of botulism from toxin types A, B, and E in the United States, 1975–1988. J Infect Dis. 1992;166:1281–6.
Pujar T, Spinello IM. A 38-year-old woman with heroin addiction, ptosis, respiratory failure, and proximal myopathy. Chest. 2008;134:867–70.
Wenham TN. Botulism—a rare complication of injecting drug use. Emerg Med J. 2008;25(1):55–6.
Schroeter M, Alpers K, Van Treeck U, Frank C, Rosenkoetter N, Schaumann R. Outbreak of wound botulism in injecting drug users. Epidemiol Infect. 2009;137:1602–8.
Kongsaengdao S, Samintarapanya K, Rusmeechan S, Sithinamsuwan P, Tanprawate S. Electrophysiological diagnosis and patterns of response to treatment of botulism with neuromuscular respiratory failure. Muscle Nerve. 2009;40:271–8.
Barry J, Ward M, Cotter S, MacDiarmada J, Hannan M, Sweeney B, Grant KA, McKeown P. Botulism in injecting drug users, Dublin, Ireland, November–December 2008. Eurosurveillance 2009; 14(1):pii.19082.
Passaro DJ, Werner BS, McGee J, Mac Kenzie WR, Vugia DJ. Wound botulism associated with black tar heroin among injection drug users. JAMA. 1998;279:859–63.
Galldiks N, Nolden-Hoverath S, Kosinski CM, et al. Rapid Geographical Clustering of Wound Botulism in Germany after subcutaneous and intramuscular injection of heroin. Neurocrit Care. 2007;6(1):30–4. doi:10.1385/NCC:6:1:30.
Gutzwiller FS, et al. Botulism—prevention, clinical diagnosis, therapy and possible threat. Dtsch Med Wochenschr. 2008;133:840–5.
Brett MM, Hallas G, Mpamugo O. Wound botulism in the UK and Ireland. J Med Microbiol. 2004;53:555–61.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no competing interests.
Rights and permissions
About this article
Cite this article
Qureshi, I.A., Qureshi, M.A., Rauf Afzal, M. et al. Black Tar Heroin Skin Popping as a Cause of Wound Botulism. Neurocrit Care 27, 415–419 (2017). https://doi.org/10.1007/s12028-017-0415-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12028-017-0415-6